ADAP Assistance Programs

 

Health Insurance Premium Payment (OA-HIPP) Assistance

The Health Insurance Premium Payment program pays for health insurance premiums and certain outpatient medical out-of-pocket costs for eligible California residents co-enrolled in the ADAP Program.

To be eligible for the OA-HIPP program, a client must:  

• Be enrolled in ADAP  
• Be enrolled in comprehensive health care coverage 
• Not be fully covered by Medi-Cal  

OA-HIPP Benefits 

• OA HIPP premium maximum:  $1,938 per month in combined premiums 
• Combined premiums include the cost for medical, dental, and vision-combo plans  
• Premium payments are sent directly to the health plan on a monthly basis 
• OA-HIPP can cover medical, dental, and vision insurance combination plan premiums 
• OA HIPP pays for out-patient out-of-pocket costs towards the medical insurance plan's annual maximum   

Covered California Clients:  If a client received OA-HIPP assistance in the previous tax year, they must submit their most recent signed and dated federal tax return as well as IRS form 8962 and 1095 A (or IRS form 4868 for a tax extension) on their first recertification or reenrollment after April 15th..

Dental and Vision Plans:  Dental plans can be covered only if a client is already enrolled in OA-HIPP for a health insurance plan. Vision plan can also be paid but only if included as part of a combined health or dental plan. 

Medical Out-of-Pocket Benefit: CDPH will also pay outpatient medical out-of-pocket costs towards the client's health insurance policy's annual out of pocket maximum for clients who are enrolled in the OA-HIPP and Employer-Based Insurance (EB-HIPP) program. All OA-HIPP and EB-HIPP eligible clients receive a client ID card to provide to medical providers when they receive services. 

Spouses and dependents, who are enrolled in ADAP themselves and listed as a family member on the OA-HIPP or EB-HIPP client's health insurance plan, are also eligible for the medical out-ofpocket benefit. Spouses and/or dependents can enroll in the Spousal-Dependent medical out-of pocket program.

Medicare Part D Premium Payment (MDPP) Assistance 

The Medicare Part D Premium Payment Program (MDPP) pays Part D and Medigap insurance premiums for persons living with HIV/AIDS who are enrolled in ADAP and a Medicare Part D prescription drug plan. Individuals that are enrolled in MDPP are also eligible for the medical out-of-pocket (MOOP) cost benefit, which covers outpatient MOOP costs towards the client's health insurance policy's annual out of pocket maximum.

To be eligible for Medicare Part D premium assistance, clients must:  

• Be enrolled in ADAP  
• Be enrolled in a Medicare Part D Prescription Plan  
• Not be receiving 100% assistance from Medicare's Extra Help/Full Low Income Subsidy 
• Medicare Part D premium maximum:  $1,938 per month. 
• Medigap premium maximum:  $1,938 per month. 
• Premium payments are sent directly to the health plan on a monthly basis. 
• MDPP pays for outpatient MOOP costs towards the plan's annual out-of-pocket max 
• MOOP reimbursements are sent directly to the rendering provider.

Employer Based Health Insurance Premium Payment (EB-HIPP)

EB-HIPP is a program that provides premium assistance for an ADAP client's portion of their employer based insurance premiums.  EB-HIPP pays the client's portion of their monthly medical and dental premiums, if eligible.  If a vision premium is included in the medical or dental, the client will have their vision subsidized.

To be eligible for the EB-HIPP program, a client must:  

• Be enrolled in ADAP 
• Be employed by an employer that offers comprehensive health care coverage 
• Be enrolled in an employer-based insurance policy   
• Have their employer sign an EB-HIPP Participation Agreement form

EB-HIPP Benefits

• EB-HIPP premium maximum:  $1,938 per month in combined premiums 
• Combined premiums include the cost for medical, dental, and vision combination plans  
• The clients portion of the insurance premium is sent directly to the employer monthly 
• EB-HIPP can cover medical and dental premiums. If a vision premium is included in the medical or dental premium, the client will have their vision subsidized.  
• EB-HIPP pays for outpatient medical out-of-pocket (MOOP) costs that count towards the medical insurance plan's annual out-of-pocket maximum. 
• Reporting Employer or Premium Changes for EB-HIPP 
• If the client's insurance or employer has changed mid-year, the client will be required to resubmit the completed Participation Agreement form and paystub dated within 3 months 
• Dental plans can be covered only if a client is enrolled in EB-HIPP for a health plan. 
• Vision insurance can also be paid but only if included as part of a combo plan.  
• EB-HIPP clients can remain on the program as long as they meet program requirements.